Evidence-based update on

chest tube management Is your practice current?

By Randelle I. Sasa, MA, RN-BC, CMSRN, CCRN

CHEST thoracotomy tubes CTT insertion (CTTs) have been around for When a provider orders a centuries, but not until the CTT, your responsibilities in- late 1950s did they become clude verifying patient iden- standard of care for treating tification, ascertaining that empyema, pneumothorax, informed consent has been hemo thorax, hemopneumo- obtained (except in emer- thorax, and pleural effusion. gencies), and determining CTTs can be life-saving, but patient understanding of the only if managed based on pro cedure. Explain the pro- current best evidence. cedure to the patient, assess his or her compre hen sion, Breathing basics answer questions within Understanding CTTs begins your purview, and allow the with understanding how breathing case is tension pneumothorax, patient to express his or her anxi- works. Ventilation, a two-part which is characterized by progres- ety. Taking these steps will im- process, begins with inhalation. sive accumulation and trapping of prove patient cooperation during The chest cavity expands, mostly air in the pleural cavity, causing the procedure. through dia phragm contraction, low- pressure buildup that obliterates Hemorrhage is a potential compli- ering pressure inside the chest cav- space for adjacent structures (lungs, cation of chest tube placement, so ity and effectively creating suction. vena cava, and heart). CTTs drain review the patient’s medications Air moves from the atmosphere of fluid and air in the pleural cavity (look for heparin, warfarin, apixa- greater pres sure and into the tho- to promote lung re-expansion. ban) and coagulation profile (activat- racic cavity, where pressure is Now that you understand the ed partial prothrombin time, interna- lower. This is negative pressure ven- phys iology, you’re ready to dive in- tional normalized ratio, platelets, and tilation. The second part of ventila- to the details of CTT management. fibrinogen). Anticoagulant use is a tion, exhalation, is passive as the relative contraindication to CTT in- diaphragm and other respiratory sertion, but the provider will weigh muscles resume their resting config- the risks and benefits. CNE uration. The decreased size of the 1.66 contact You’ll also be involved in gather- lungs reverses the pressure gradi- hours ing supplies, administering antibiotic ent, and air is forced out into the at- and pain prophylaxis as ordered, as- mosphere. LEARNING OBJECTIVES sisting with selecting and imaging the Between the outer lining of the 1. Describe patient care related to in- insertion site, positioning the pa- lungs and the inner chest wall lies sertion of a chest thoracotomy tube tient, ensuring sterile technique, the pleural space, which normally (CTT). securing≥ the tube, and confirming is lubricated by pleural fluid in the 2. Discuss management of patients placement. amount of 0.2 mL/kg (10 to 20 mL with a CTT in place. Gather supplies: As ordered by for average-size adults). When pleur - 3. Identify CTT complications. the provider, prepare the CTT in-

al integrity is breached, excess The author and planners of this CNE activity have sertion tray, tube, and drainage blood, serous fluid, or air accumu- disclosed no relevant financial relationships with system. (See Small bore or large any commercial companies pertaining to this activ- lates. The body can handle small ity. See the last page of the article to learn how to bore?) Set up chest drainage units amounts of extra pleural fluid or earn CNE credit. (CDUs) per the manufacturer’s rec- air, but large amounts (≥ 300 mL) ommendations. For underwater impede ventilation. An extreme seal CDUs, the most important prep -

10 American Nurse Today Volume 14, Number 4 AmericanNurseToday.com Small bore or large bore?

Chest thoracotomy tube drains are either small-bore or large-bore. aration is filling the water seal cham - ber with sterile water or sterile Small-bore drains • Size: 8.5 to 14 Fr normal saline to the prescribed • level (2 cm). As part of your safety Recommended as firstline treatment for pneumothoraces, pleural effusions, and pleural infections and contingency preparations, • keep petroleum gauze and a rub- Less patient discomfort • Less severe complications ber-tipped clamp at the patient’s bedside, especially during trans- Large-bore drains fers, in case of complications. • Size: 24 to 32 Fr Antibiotic and pain prophy- • Used for most adults laxis: Antibiotic prophylaxis is • Recommended for acute hemothorax to monitor blood loss recommended only for patients with traumatic chest injuries. In addition to 1% lidocaine injected around the incision site to reduce pain, premedication with an I.V. Tape: A little goes a long way analgesic and/or an anxiolytic is In addition to suturing, a chest thoracotomy tube recommended. (CTT) should be secured with tape a few inches be- Site selection and imaging: CTTs low the insertion site to prevent accidental dislodg- are usually inserted in the 4th or 5th ment and dependent loops. The omental tape tech- intercostal space just anterior to the nique fastens the tube securely while allowing some midaxillary line. Imaging guidance distance between the skin and the tube to prevent during CTT insertion is strongly rec- kinking and tension at the insertion site. ommended, so make sure that a func - Too many nurses think that more tape leads to tional and disinfected ultrasound ma- more secure CTTs, but the evidence doesn’t support chine is in the patient’s room before that. In addition to being wasteful and unnecessary, the procedure. excessive tape may impede chest wall expansion. It also can increase moisture collection between the Patient positioning: Optimal skin and the adhesive, which may lead to infection. Omental tape technique positioning during the procedure requires balancing the patient’s overall condition and comfort with the provider’s access to the ile gloves, drapes, and gowns. CDUs ana tomic structures. Guidelines in- Securing the tube: After inser- CDUs ensure negative pressure with- dicate that the preferred patient tion, providers secure the CTT with in the chest cavity by facilitating position is semi-reclined at a 45- heavy, nonabsorbable suture (0 or unidirectional flow of drainage degree angle, boosted by a small 1-0 silk). Dressings and tape are (pleural fluids, blood, or air) from wedge or linen to fully expose helpful, but nothing secures a chest the intrapleural space into the the side to be operated on. The tube better than stitching it in place. CDU’s collection chamber. CDUs patient’s forearm is raised above (See Tape: A little goes a long way.) are categorized according to size the head, and the hand is tucked Insertion site dressings: The and their mechanism for prevent- behind the head. Secure any other literature presents several ways of ing air and fluid from entering the potential obstructions to the sur- dressing a CTT insertion site, but pleura. Underwater seal CDUs are gical site, such as a pendulous little evidence supporting their ef- larger and have two chambers (a breast, before the procedure. fectiveness exists. (See Insertion drainage collection chamber and If the patient can’t tolerate lying site dressing options.) In most prac- water seal chamber). (See Under- in bed, he or she may assume the tice settings, the provider who water seal CDUs). One-way valve orthopneic position, sitting up with placed the CTT selects the dress- CDUs are smaller and more an overbed table in front to lean on ing. The nurse performs postinser- portable. (See One-way valve CDU.) and a pillow placed under the arms tion dressing changes according to Both small- and large-bore CTTs for comfort. This allows maximal organizational policy. can be attached to either category expansion of the lungs while ex- Confirming placement: An X- of CDU. The provider selects the posing the midaxillary area. ray usually is needed to confirm CTT appropriate CDU type for the pa- Aseptic technique: Guidelines placement after insertion. Studies in- tient by anticipating the amount of recommend full aseptic technique, dicate that daily chest X-rays to mon- drainage and whether suction will which includes skin cleansing, ster- itor placement aren’t warranted. be needed.

AmericanNurseToday.com April 2019 American Nurse Today 11 Insertion site dressing options

Underwater seal CDU The classic dressing for chest thoracotomy tube Drainage collection chamber: (CTT) insertion sites is petroleum gauze held in Drainage collection chambers, which place by a secondary dressing of sterile, 4" x 4" typically have a 2,100-mL capacity, sponge gauze secured with tape. Studies suggest have calibrations and numeric mark- that petroleum gauze macerates skin over time. ings for measuring output. Best Other dressing materials have been explored, in- practice is to mark the drainage lev- cluding dry occlusive dressings, standard gauze, and transparent film. A randomized controlled trial el and write the date and time of by Gross and colleagues found no significant differ- each reading on the face of the ence in the effectiveness of petroleum gauze, dry CDU. The provider orders output sterile dressing (bordered gauze), and no dressing. monitoring frequency, but at a min- However, the sample size was small, so the result imum, do it at the start and toward can’t be generalized. the end of your shift. Transparent film can be used alone or as a sec- Water seal chamber: The water ondary dressing to avoid using tape. It also allows better visualization of the CTT to monitor for tube CTT insertion site dressing with seal chamber prevents atmospher- transparent film on top ic air from going into the pleural migration. space. Any air in the pleural space will drain through the CTT and pass through the collection chamber and • water spillage if the CDU is Managing patients with a CTT into the water seal chamber, where knocked over If you follow a few practical tips, it appears as intermittent bubbling. • evaporation that necessitates managing patients with a CTT won’t This is normal and expected. adding more sterile water to the be complicated. Continuous bubbling in the wa- suction control Monitor patient response. Fo- ter seal indicates an air leak. Check • bubbling and gurgling sounds cus your assessment on the patient, all connections for looseness and that may annoy patients and in- not the equipment. Every 2 hours secure with tape. Complete absence terfere with sleep (or as needed), assess and document of bubbling may indicate chest re- • manufacturer-recommended ma- the patient’s level of consciousness, expansion or a system malfunction. neuvers to achieve more suction orientation, vital signs (especially Tidaling or oscillations also are than that provided by the cham- respiratory rate, depth, and effort), observable in the water seal cham- ber’s –20 cmH2O maximum. breath sounds, and oxygen satura- ber and coincide with respirations. Dry suction CDUs were created tion. Every 8 hours (or as needed), Tidaling is normal; its absence may to improve wet suction systems. inspect the CTT insertion site for indicate chest re-expansion. The water column is replaced by a drainage, subcutaneous emphyse- Suction control mechanism: knob and internal valves to control ma, and tube migration. CDUs can be used with or without suction. The suction monitor bel- Maintain CTT and drainage suction, but all CDUs have built-in lows provide visual confirmation system integrity. Remember that mechanisms to regulate the amount that suction is being applied. Dry the CTT system will work only if of suction being applied. suction CDU advantages include: it’s intact. Any breach in the sys- To apply suction, connect the • quiet operation tem—even a loose connection—can CDU to a wall suction unit, and turn • accurate and consistent amount allow atmospheric air to get sucked the gauge to no less than –80 mmHg of suction because of evapora- into the thoracic cavity, causing pa- (medium suction setting). Note that tion elimination tient harm. Secure and monitor all not all of this –80 mmHg of suction • suction up to –40 cmH2O with points of connection. Activities of goes into the patient. The amount the turn of a knob daily living (ADLs) such as bathing, of suction applied to the patient is • less chance of fluid spills. repositioning and turning, and am- regulated by the CDU, not the wall bulating can loosen or dislodge CTT gauge. There are two suction con- One-way valve CDU connections. Assist patients during trol mechanisms—wet versus dry. In cases of pneumothorax where any of these activities. Wet suction CDUs, which are only air and a scant amount of Ensure continuous drainage by more traditional, use the amount of drainage are expected, one-way gravity. The whole system should sterile water added to the chamber valve devices may be more practi- be kept patent, and the CDU must to regulate suction. As suction is ap- cal. When using this type of CDU, be positioned lower than the inser- plied, continuous bubbling occurs note that you won’t be able to easi- tion site. in the suction control chamber. Wet ly observe air leaks, monitor in- • Keep all tubing free of kinks, oc- suction CDU disadvantages include: trapleural pressures, or use suction. clusions, and dependent loops;

12 American Nurse Today Volume 14, Number 4 AmericanNurseToday.com Underwater seal CDUs

Underwater seal chest drainage unit (CDU) design is based on the classic three- way bottle system, with three distinct chambers in a sterile, integrated system: When caring for patients with a • drainage collection chamber CTT, keep petroleum gauze and a rubber-tipped clamp at the bedside. • water seal chamber • Be prepared to address some of suction control chamber/mechanism. A wet-suction CDU has a suction control these common events. chamber, while the dry-suction CDU replaces this with a regulator and suction • Tube dislodgment. Dislodgment monitor bellows. requires prompt application of A CDU also has additional features such as an air leak monitor, needleless access petroleum gauze to the insertion port, and a positive pressure release valve. See an image of a CDU at opentextbc.ca/ site and provider notification. clinicalskills/chapter/10-7-chest-drainage-systems/. • CDU contamination or mal- function. If the CDU is discon- nected, contaminated, or mal- they can dramatically increase sure usually is a problem only functions, it may have to be intrathoracic pressure in just a in wet suction systems. If the changed while the CTT remains few minutes. ordered suction amount is –20 secured in its insertion site. In • CTTs are rarely clamped because cmH2O, then the suction control these situations, disconnect the it heightens the risk of causing chamber should be filled with CTT from the CDU and promptly tension pneumothorax. If clamp- sterile water to that exact level. submerge it 1 to 2 inches in a ing is done, usually it’s a trial You can add (or remove) sterile 250-mL bottle of sterile water to before CTT removal. Clamping water from the suction control establish a seal. Ask a coworker might also be done after pleu- chamber as needed. to obtain a new CDU and recon- rodesis, which is a procedure to Monitor drainage. Monitor the nect the CTT. Another option is mechanically or chemically oblit- amount and quality of drainage. Err to clamp the CTT using a rub- erate the pleural space where flu- on the safe side and notify the pro - ber-tipped clamp or forceps, but id buildup emanates. Clamping vider if output exceeds 100 mL. only for a few minutes to obtain always requires a provider order. Any drastic increase or decrease in supplies. Remember that clamp- Pay attention to the water seal volume or change in quality (color, ing poses the risk of tension chamber. If you witness excess bloodiness, or purulence) of the pneumothorax. bubbling, assume that the seal is drainage may indicate a problem • CDU knocked over. If the CDU being breached and air is leaking. and also requires notifying the gets knocked over, promptly re- Check and secure all connections. provider. turn it to its upright position and Note that tidaling and intermittent Prepare for untoward events. check all connections. Although bubbling are normal. most CDUs have mechanisms to Mind the pressures. When car- contain fluids in their respective ing for patients with CTTs, monitor: One-way valve CDU chambers, thoroughly inspect • intrathoracic pressure. Intra- them. Check the water seal cham- thoracic pressure can be gauged Smaller, one-way valve chest drainage ber first, and make sure that the by looking at the water seal units (CDUs) are portable and more prac- sterile water is at the 2-cm mark. chamber. Safety vents in CDUs tical when only air or a small amount of In wet suction CDUs, check the dispel excess negative pressure drainage is expected. suction control chamber and add and any buildup of positive sterile water as needed. pressure. Intrathoracic negativ- One-way Don’t milk or strip. Milking or ity can be damaging if it exceeds valve stripping refers to aggressive ma- –20 cmH2O. It can be caused by neuvers that force large blood clots respiratory distress, coughing, Air leak into the CDU. This sharply increas- and crying, as well as activities indicator es intrathoracic pressure and can such as stripping or milking the Luer-lock harm the patient. If needed, pinch Stepped tube. You can remedy persist- connector and release the tube, one small ently high intrathoracic negativi- connector segment at a time, until clots fall off ty by manually pressing on the the tube. high-negativity vent at the back Collection Provide patient education. Pa- of the CDU. Important: This can chamber tient education should include the be done only if suction is being reason for the CTT and basics applied. about how the system works. Em- • suction pressure. Suction pres- phasize the importance of partici-

AmericanNurseToday.com April 2019 American Nurse Today 13 CTT checklist

Use this comprehensive chest thoracotomy tube (CTT) checklist at least once every shift as a reminder for monitoring and managing patients with a CTT.

!"#$%!% #&'$%!% ("#&$)#% Does patient show signs of respiratory distress? yes/no? Is lung expansion symmetric? yes/no? What is the patient’s pain score @ insertion site? 1–10 What are the breath sounds on the side being treated with a chest tube? Describe. Indicate if patient performed deep breathing exercises (DBE), coughing (C), or ambulation (A) this shift. &)*$+#&,)%*&#$% Insertion site dressing intact? yes/no? Is dressing change done during this shift? yes/no? Is there subcutaneous emphysema? yes/no? Specify level of chest tube exposed @ insertion site. cm cm cm cm cm cm cm cm cm cm cm cm -,))$-#&,)*% Correct connector size yes/no? Connections are secure? yes/no? Are tubings kinked? yes/no? Are tubings clamped? yes/no? Are there dependent loops? yes/no? -.$*#%!+"&)"/$%0)&#%1-!02% Specify type of unit WET or DRY suction? Is water seal at level of 2 cm? Is there tidaling/oscillation @ water seal chamber? yes/no? Indicate if there is intermittent (I), continuous (C), or no (NO) bubbling @ water seal chamber. Color of water seal unchanged? yes/no? Is suction applied? yes/no?

Specify amount of suction.

Is the correct amount of suction applied? yes/no?

Is there excessive negative pressure @ water seal? yes/no?

Is CDU located below level of patient’s chest? yes/no? !+"&)"/$% % % % % % % % % % % % %

Specify amount of drainage (refer if >100 mL or acute change) mL mL mL mL mL mL mL mL mL mL mL mL

Specify color of drainage (refer for changes)

Remarks !

RN’s initials ! pating in care activities and: and/or air leak. Traditionally, the to monitor the patient’s respiratory • being vigilant in monitoring for CTT is removed when drainage is function, vital signs, CTT postinser- integrity of the CTT system, es- less than 100 mL/day. Current litera- tion site, and overall comfort level. pecially after ADLs ture is more aggressive, citing that • performing deep breathing and CTTs can be removed safely when Breathe! coughing exercises hourly during output is less than 400 mL/day, in Evidence supports the use of check- waking hours, as ordered the absence of air leaks. lists to improve nursing care of pa- • ambulating with assistance after To prepare for CTT removal: tients with a CTT. Checklists pro- cleared by the provider • gather supplies, including forceps/ vide a visual aid, reminder, and • calling the nurse or provider if clamp, pad for drainage, dress- quick reference about monitoring any change in breathing pattern ing set, and occlusive dressing and care. (See CCT checklist.) And occurs. • place the patient in semi-Fowler’s when taking care of a patient with position a CTT, take a moment to breathe CTT removal • teach the patient how to perform and focus on the task at hand. Re- The CTT may be discontinued when the Valsalva maneuver (unless member the basics and stay calm. evidence of lung re-expansion is ob- contraindicated or the patient is You got this. served, such as improved X-rays, unable) when the provider pulls symmetric chest expansion, absence the tube Visit americannursetoday.com/?p=55741 for a list of selected references. of tidaling, and improved overall • administer pain medications respiratory function. However, the and/or anxiolytics as ordered. Randelle I. Sasa is an assistant professor of nursing primary consideration for CTT re- After the CTT is removed, an X- at Queensborough Community College, City Universi- moval is the amount of drainage ray is taken and you will continue ty of New York in Bayside.

14 American Nurse Today Volume 14, Number 4 AmericanNurseToday.com